MALE INFERTILITY

Earlier, infertility was thought to be a woman’s problem but now it has turn out to be a man’s problem too. Studies have shown that around one out of each 3 instances of infertility is because of the man alone. Moreover, the diagnosis of male infertility can be one of the hardest challenges a person can face. For some, it can be very distressing and frustrating.Unfortunately, some men have to deal with the reality that nothing can be done about their infertility. But for other men, advances in male infertility treatment offer real help.

SYMPTOMS
The main sign of male infertility is the inability to conceive a child even after one year of trying. There are no other obvious signs or symptoms to detect male infertility. However, in some cases, problems such as abnormal hormone levels, inherited disorder, dilated veins around the testicles, or blockage of the passage of sperms could be some of the signs and symptoms.
Some of the signs and symptoms associated with male infertility are listed below:
• Problems with sexual function such as difficulty with ejaculation, erectile dysfunction, or reduced sexual desire.
• Pain and swellingin the testicle area
• Recurrent respiratory infections
• Abnormal breast growth (gynecomastia)
• Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
• Low sperm count

CAUSES
Male infertility is a very complex process and the factors responsible for causing this condition are listed below:
• Unhealthy sperm production: This usually occurs when the testicles are not functioning correctly. Testosterone hormone helps in sperm production. If the secretion of this hormone is abnormal, sperm production suffers.
• Epididymal Obstruction: It occurs when there is a blockage in epididymis, preventing sperm from getting into the ejaculate.
• Low sperm concentration: If the sperm concentration i.e. the number of sperm in semen is low then it could reduce the chances of fertilizing an egg. According to WHO 2010, a low sperm concentration is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
• Low sperm motility: If sperm motility is low then the sperm may not be able to reach or penetrate an egg.

MEDICAL CAUSES
Problems with male fertility can be caused by several health issues and medical treatments. Some of these include:
• Varicocele: A varicocele is a swelling of veins that drain the testicle. It is the most common reversible cause of male infertility. Although the exact cause of varicocele is unknown but it may be related to abnormal testicular temperature.
• Infection: Infections such as epididymitis or orchitis i.e. inflammation of testicles or sexually transmitted diseases can interfere with sperm production or can cause scarring that blocks the passage of sperm.
• Retrograde ejaculation: It occurs during ejaculation when semen rather emerging out the tip of the penis, enters the bladder. Many health conditions are responsible for causingretrograde ejaculation, including diabetes, spinal cord injury, and surgery of the bladder, prostate, or urethra.
• Malignancy: Both malignant and non-malignant tumors can affect the male reproductive organs directly, either by affecting the glands responsible for the release of reproduction-related hormones or by causing testicular damage. Even the anti-malignancy treatments such as surgery, radiation, or chemotherapy can affect male fertility to a great extent resulting in permanent sterility or long-term sterility up to 5 years depending on the dose and the duration of the treatment.
• Undescended testicles: In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
• Hormone imbalances: Hormonal imbalances can occur due to any abnormality affecting the systems necessary to regulate such levels inside the body. Such systems include the hypothalamus, pituitary, thyroid, and adrenal glands.
• Chromosome defects: Inherited disorders such as Klinefelter's syndrome in which a male is born with two X chromosomes and one Y chromosome instead of one X and one Y, cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosisand Kallmann's syndrome.
• Problems with sexual intercourse: These can include erectile dysfunction, premature ejaculation, painful intercourse, or anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias).
• Certain medications. Medications such as testosterone replacement therapy, long-term use of steroids, certain antifungal and ulcer drugs can impair sperm production and may cause male infertility.
• Prior surgeries. Certain surgeries such as scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers and inguinal hernia repairs may impact on sperm production.

ENVIRONMENTAL CAUSES
Environmental factors such as over-exposure to heavy metals, pesticides, radiation, etc could potentially influence sperm quality. Some of the specific causes are listed below:
• Industrial chemicals: Exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials, may contribute to low sperm counts, hormonal imbalances, increased rates of miscarriages, etc.
• Heavy metal exposure: Exposure to heavy metals like lead, cadmium, and mercury may cause low sperm counts, decreased sperm density, motility, and morphology.
• Radiation: Depending on its dose and duration, it can reduce sperm production or may cause permanent sterility.
• High temperature: Elevated temperatures impair sperm production and function.Sitting for long periods, wearing tight clothing, or working on a laptop computer for long periods and keeping the mobile phone in lower front pocket of trouser also may increase the temperature in the scrotum and may slightly reduce sperm production.

LIFESTYLE CAUSES
Lifestyle factors are amendable habits and ways of life that can greatly influence overall health and well-being, including fertility. Advancing paternal age, the occupation has been implicated in a broad range of abnormal reproductive and genetic outcomes. Lifestyle factors, including age when starting a family, nutrition, weight management, exercise, psychological stress, cigarette smoking, recreational and prescription drug use, alcohol and caffeine consumption, and use of mobile phones may impact fertility.

DIAGNOSIS
Diagnosing a male for infertility problems usually involves:
• General physical examination and medical history: A standard reproductive history and physical exam should be performed which includes examining genitals and questioning about any inherited conditions, chronic health problems, illnesses, injuries, or surgeries that could affect fertility.
• Semen analysis: For this,the sample should be collected in a private room near the laboratory, to limit the exposure of the semen to fluctuations in temperature and to control the time between collection and analysis. The sample should be obtained by masturbation without applying any jelly or cream and ejaculated into a sterile clean wide-mouthed container.
The sample is then tested in a laboratory to measure the number of sperm present and look for any morphological abnormalities and motility of the sperm. Also, semen is checked for signs of problems such as infections.
According to WHO 2010, a semen sample is said to be normal if has following parameters in lower reference values:
SEMEN PARAMETERS LOWER REFERENCE VALUES
Semen volume (ml) 1.5 (1.4 – 1.7)
Sperm concentration (106/ ml) 15 (12 - 16)
Total sperm count (106/ ejaculate) 39 (33 - 46)
Total motility (PR + NP) 40 (38 - 42)
Progressive Motility, % 32 (31- 34)
Vitality, (live spermatozoa, %) 58 (55 - 63)
Sperm morphology (normal forms, %) 4 (3.0 – 4.0)
Round cell concentration Less than 1 x 106 per ml

• Scrotal ultrasound. This test uses high-frequency sound waves to produce images inside the body. A scrotal ultrasound can help to see if there is a varicocele or other problems in the testicles and supporting structures.
• Hormone testing: A blood test is recommended to measure the minimum initial hormone levels which include measurement of serum FSH and total T concentrations, although most cases will require complete hormone testing, including luteinizing hormone (LH), free T, estradiol, and prolactin
• Post-ejaculation urinalysis: This is done to eliminate the chances of retrograde ejaculation.
• Genetic evaluation: The causes of male infertility are often multifactorial. Males with low sperm count or no sperm may have approximately 50% genetic abnormalities. It is generally ordered to diagnose various congenital or inherited syndromes and recommended in patients whose sperm concentration is very low.
• Testicular biopsy: Diagnostic testicular biopsy or aspiration is primarily indicated if there is uncertainty whether the patient has obstructive or non-obstructive azoospermia.
• Specialized sperm function tests. Several tests can be used to check the survivability of sperm after ejaculation, their egg penetration ability, their egg binding potential, their DNA integrity, levels of reactive oxygen species in semen, sperm maturity, etc. Generally these tests are rarely performed and are not recommended for all patients.

TREATMENT
After finding out the exact cause of infertility, accordingly the treatment process is designed for a particular couple, keeping in mind both male and female factors. Treatments for male infertility include:
• Surgery: Surgery is used to treat the following:
o Severe varicocele
o Vas deferens obstruction
o Reversal of vasectomy
o Azoospermia (which is defined as the absence of sperm in at least two different ejaculate samples 4 weeks apart including the centrifuged sediment). In such cases, sperm can often be retrieved directly from the testicles or epididymis using spermretrieval techniques.
• Treating infections: Antibiotic treatment might cure an infection of the reproductive tract, but doesn't always restore fertility.
• Treatments for sexual intercourse problems: Medication or counseling can help improve fertility in conditions such as erectile dysfunction or premature ejaculation.
• Hormone treatments and medications: Hormone replacement or medications in cases where infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones.
• Assisted Reproductive Technology (ART). ART treatments involve obtaining sperm through normal ejaculation, surgical extraction, or from donor individuals, depending on the case. The semen is prepared and finally inseminated into the female genital tract for Intrauterine insemination (IUI) or used to perform In-vitro Fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI).

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